Opioids and Heroin: A New Look at Some Old (and Not So Old) Drugs

On September 18, 2018 the DEA Museum will host a panel discussion on “Opioids and Heroin: A New Look at Some Old (and Not So Old) Drugs.”

Drug overdoses are now the leading cause of injury-related death in the United States, eclipsing deaths from motor vehicle crashes or firearms. According to the Centers for Disease Control and Prevention (CDC), there were nearly 64,000 overdose deaths in 2016, or approximately 174 per day. Over 42,249 (66 percent) of these deaths involved opioids. CDC’s preliminary data estimates more than 74,000 drug overdose deaths in 2017.

Experts in the opioid epidemic and the heroin threat will discuss the crisis of opioid addiction and overdose. This event is free and open to the public.

Program Description

Drug overdoses are now the leading cause of injury-related death in the United States, eclipsing deaths from motor vehicle crashes or firearms. According to the Centers for Disease Control and Prevention (CDC), there were nearly 64,000 overdose deaths in 2016, or approximately 174 per day. Over 42,249 (66 percent) of these deaths involved opioids. CDC’s preliminary data estimates more than 74,000 drug overdose deaths in 2017.

The misuse of controlled prescription drugs (CPDs) and the growing use of heroin, illicit fentanyl, and fentanyl analogues are being reported in the United States in unprecedented numbers. According to the Substance Abuse and Mental Health Services Administration (SAMHSA) 2016 National Survey on Drug Use and Health (NSDUH), 6.2 million people over the age of 12 misused psychotherapeutic drugs (e.g., pain relievers, tranquilizers, stimulants, and sedatives) during the past month. This represents 22 percent of the 28.6 million current illicit drug users and is second only to marijuana (24 million users) in terms of usage.

There are more current misusers of psychotherapeutic drugs than current users of cocaine, heroin, and hallucinogens combined.

The U.S. opioid overdose epidemic is still worsening: emergency department visits for suspected opioid overdoses increased 30% in 45 states between July 2016 and September 2017, and all five U.S. regions experienced rate increases.

The sharp increase in drug overdose deaths was fueled by a surge in fentanyl and fentanyl analogue (synthetic opioids) involved overdoses.

The increase in the number of people using heroin in recent years – from 373,000 past year users in 2007 to 948,000 in 2016 – is troubling. More alarming is the proliferation of illicit fentanyl and its analogues. DEA investigations reveal that illicit fentanyl and its analogues are increasingly being added to heroin and frequently pressed into counterfeit tablets resembling CPDs. Overdose deaths involving heroin are increasing at an alarming rate, having increased more than five-fold since 2010.

The United States continues to be affected by a national opioid epidemic, which has been spurred, in part, by the rise of opioid prescribing and misuse. Of the 11.5 million Americans reporting past-year misuse of opioid prescription medicines, many may have actually misused a counterfeit prescription pain medication.

Dr. Teresa Rummans,M.D. Professor at the Mayo Clinic will discuss “How Good Intentions Contributed to Bad Outcomes: The Opioid Crisis.” In a recent paper, Dr. Rummans and her co-authors describe the origins of the opioid crises. Thirty years ago, a claim that those suffering from chronic pain who received opioids rarely became addicted changed prescriber attitudes towards opioid use. She describes the transition from opioids being reserved for treatment of acute or terminal pain conditions and instead being used to treat any pain condition.

Rummans points out that governing agencies began to evaluate doctors and hospitals on their control of patients’ pain. Ultimately, reimbursement became tied to patients’ perception of pain control. As a result, increasing amounts of opioids were prescribed, leading to dependence. When this occurred, patients sought more in the form of opioid prescriptions from providers or from illegal sources. Illegal, unregulated sources of opioids are now a factor in the increasing death rate from opioid overdoses.

Good intentions to improve pain and suffering led to increased prescribing of opioids, which contributed to misuse of opioids and even death. Rummans emphasizes that stopping the opioid crisis will require the engagement of all. This includes health care providers, hospitals, the pharmaceutical industry, and federal and state government agencies.

Bruce Goldberger, Ph.D., Professor, University of Florida will discuss “The Opioid Crisis – An Epidemic of Overdoses and Deaths.” Dr. Goldberger tracks drug use data and deaths throughout Florida through the Florida Drug-Related Outcomes Surveillance and Tracking System, which helps fight prescription drug abuse. He also studies the effects of fentanyl on medical examiner offices across the country. Illicit labs change fentanyl formulations, and medical examiner offices often lack appropriate testing methods with which to identify them.

Goldberger served as an advisor to the Centers for Disease Control’s Enhanced State Opioid Overdose Surveillance program. The program tracked fatal opioid overdoses in 12 states in fiscal year 2016. The program report found that the number of opioid overdose deaths is increasing, including heroin-related overdose deaths. The increased overdose rate is exacerbated by fentanyl, which is mixed with opioids and other drugs–like cocaine, methamphetamine, and benzodiazepines. The increase in opioid overdose deaths in 2016 was driven by a fivefold increase in overdose death involving synthetic opioids.

The CDC’s program was the first to use toxicologic and death scene evidence across multiple states to characterize opioid overdose death. Increasing mixing or co-use of fentanyl, heroin, cocaine, and fentanyl analogs might contribute to increased overdose risk, because users are exposed to drug products that vary substantially in potency and that include some extremely potent products. Goldberger notes the need to expand surveillance for opioid overdoses to track the rapidly changing illicit opioid market.

Brian Fuehrlein, MD, Ph.D. Assistant Professor of Psychiatry, Yale University School of Medicine; Director, Psychiatric Emergency Room, VA Connecticut Healthcare System will discuss “The Use of Medication Assisted Treatment for Opioid Use Disorder in an Emergency Room Setting.”

From 1999 to 2016, more than 200,000 people died in the U.S. from overdoses related to prescription opioids. The death rate of synthetic opioids (other than methadone) increased by 100% from 2015 to 2016. The rising overdose rate is mirrored by an increased number of emergency room visits. Dr. Fuehrlein is the Director of the psychiatric emergency room at the VA Connecticut where veterans suffering from opioid addiction and overdose seek treatment. Fuehrlein points out that patients who have received an overdose treatment are at high risk for future overdoses. Many have a history of other substance use disorders, including marijuana, alcohol, cocaine, and sedatives. Fuehrlein’ s approach to a patient following medical stabilization, which often includes Narcan administration and other treatments, is to encourage medication-assisted treatment.

VA Connecticut’s patients receive a thorough psychiatric and substance use assessment upon admission. Fuehrlein recognizes the high prevalence of co-occurring psychiatric illness with opioid use disorder. He has observed that the severe psychosocial consequences and stressors associated with severe opioid use disorder may and often leads to comorbid anxiety and/or depression with a smaller number experiencing suicidal thoughts.

Fuehrlein advocates an aggressive approach in order to motivate patients who have experienced an overdose to be initiated on medication-assisted treatment. Once stabilized, patients are generally moved to a 21-day substance abuse program. He educates every patient on the need for a psychosocial support structure, which might include Alcohol or Narcotics Anonymous programs. Though some providers may not view the emergency room as an ideal environment for a recovery discovery discussion, VA Connecticut’s psychiatric emergency room patients are counseled about the importance for long-term treatment and recovery programs. Years or decades of opioid use are rarely overcome following a 21-day program. On-going treatment in a solid aftercare program that reinforces recovery principles and motivates patients to continue is critical to success, says Fuehrlein.

Dolores Breiner, Intelligence Research Specialist, Domestic Strategic Intelligence Unit, DEA will discuss “An Overview of The Heroin Situation in the United States.” The 2016 National Drug Threat Survey found that the threat posed by heroin in the United States is serious and increasing. Heroin is available in larger quantities, used by a larger number of people, and is causing an increasing number of overdose deaths. DEA Intelligence Research Specialist Breiner follows and reports on the domestic heroin threat and is working on the 2017 assessment.

Starting in late 2013, several states reported spikes in overdose deaths due to fentanyl and its analog acetyl-fentanyl. Between 2013 and 2014, there was a 79 percent increase in deaths related to synthetic opioids, the category under which fentanyl falls. The true number of synthetic-opioid-related deaths is most likely higher because of non-standardized reporting and because many coroners’ offices and state crime laboratories initially did not test for fentanyl or its analogs unless given a specific reason to do so. Further, there is no standardized system for reporting drug-related deaths in the United States. The manner of collecting and reporting death data varies with each medical examiner and coroner.

Hundreds of thousands of counterfeit prescription pills, some containing deadly amounts of fentanyl, have been introduced into U.S. drug markets, exacerbating the fentanyl and opioid crisis. Motivated by enormous profit potential, traffickers are exploiting high consumer demand for prescription medications by producing inexpensive, fraudulent prescription pills containing fentanyl.

Heroin, while used by a smaller number of people than other major drugs, is much more deadly to its users. Deaths involving heroin are also increasing at a much faster rate than for other illicit drugs. Despite comprising a smaller user population, there were more treatment admissions to publicly funded facilities for heroin than for any other drug.

The misuse of controlled prescription drugs (CPDs) is inextricably linked with the threat the United States faces from the trafficking of heroin, illicit fentanyl, and fentanyl analogues.

In 2014, 10,574 Americans died from heroin-related overdoses, more than triple the number in 2010. Increased demand for, and use of, heroin is being driven by both increasing availability of heroin in the U.S. market and by some controlled prescription drug (CPD) abusers using heroin.

Panelists

Mark S. Gold, M.D., Moderator
Dr. Mark S. Gold is Chairman of Rivermend Health’s Scientific Advisory Boards. He serves as Chairman of the Addiction & Psychiatry Scientific Advisory Board and also as the Chairman of the Eating Disorders and Obesity Scientific Advisory Board. Dr. Gold served as Professor, the Donald Dizney Eminent Scholar, Distinguished Professor and Chair of Psychiatry from 1990-2014. He was the first Faculty from the College of Medicine to be selected as a University-wide Distinguished Alumni Professor and served as the 17th University of Florida’s Distinguished Alumni Professor. Prior to assuming the position as Chair, he was a Distinguished Service Professor in the Departments of Psychiatry, Neuroscience, Anesthesiology, and Community Health and Family Medicine at the University of Florida College of Medicine. He is also a member of the McKnight Brain Institute and a Founder of the U.F. Center for Alcohol and Drug Research and Education (CARE), Adjunct, Clinical Professor in the Departments of Psychiatry & Behavioral Science at the University of Southern California’s Keck School of Medicine, a Distinguished Fellow of the American Society of Addiction Medicine (DFASAM), and on March 5th, 2015, Dr. Gold became the Director of Research, Drug Enforcement Administration (DEA) Educational Foundation working on global drug use, abuse and addiction problems and solutions.

Dr. Teresa A. Rummans, M.D., is a consultant in the Department of Psychiatry and Psychology at Mayo Clinic in both Minnesota and Florida. Dr. Rummans received her Bachelor of Arts degree from Vanderbilt University and her M.D. from the University of North Carolina, Chapel Hill. She completed a residency in internal medicine and a residency in psychiatry with Mayo Graduate School of Medicine, Mayo Clinic College of Medicine. She also completed a master’s degree in Medical Management through the University of Texas, Dallas.

Dr. Rummans served as Chair for the Department of Psychiatry and Psychology at Mayo Clinic in Florida and serves as Vice Chair for the Department of Psychiatry and Psychology at Mayo Clinic in Minnesota. She holds the academic rank of Professor of Psychiatry, Mayo Clinic College of Medicine, and was recognized with Distinguished Clinician in 2015 and the distinction of a named Professorship, the Donald C. and Lucy J. Dayton Professorship in 2016. She was elected both Secretary and then President of Mayo Clinic Staff, Mayo Clinic in Rochester, served as Chair of the Career and Leadership Development Committee at Mayo Clinic and was member of the Mayo Clinic Rochester Board of Governors. Outside of Mayo Clinic, she has served on the governing boards of the American Association of Geriatric Psychiatry, Academy of Consultation-Liaison Psychiatry and American College of Psychiatry.

Bruce Goldberger, Ph.D., Professor and the Chief of the Division of Forensic Medicine in the Department of Pathology, Immunology and Laboratory Medicine in the College of Medicine at the University of Florida-Gainesville

Dr. Bruce Goldberger is a Professor and the Chief of the Division of Forensic Medicine in the Department of Pathology, Immunology and Laboratory Medicine in the College of Medicine at the University of Florida in Gainesville. He holds a joint Professor position in the Department of Psychiatry Division of Addiction Medicine. Dr. Goldberger is the Medical Director of UF Health Pathology Laboratories Clinical and Forensic Toxicology Laboratories, the Director of the William R. Maples Center for Forensic Medicine, and the Program Director of the Florida Emergency Mortuary Operations Response System. Dr. Goldberger received a Bachelor of Arts Degree in Zoology from Drew University in Madison, New Jersey and Master of Science and Doctor of Philosophy Degrees in Forensic Toxicology from the University of Maryland School of Medicine in Baltimore, Maryland. He is the President and a Fellow of the American Board of Forensic Toxicology. Dr. Goldberger is an opioid consultant to the Division of Unintentional Injury Prevention in the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention.

Dr. Brian Fuehrlein graduated from the M.D. Ph.D. program at the University of Florida in 2008, adult psychiatry residency program the University of Texas Southwestern Medical Center in 2012 and addiction psychiatry fellowship from Yale University in 2013. Dr. Fuehrlein then joined the faculty at the University of Florida where he was an Assistant Professor. He served as the director of an MS2 course on pain and addiction, the assistant MS3 psychiatry clerkship director, was on the medical school admissions committee and on the M.D. Ph.D. program executive committee. Dr. Fuehrlein then joined the Yale faculty as an Assistant Professor in 2014. He is currently the director of the psychiatric emergency room at the VA Connecticut. Dr. Fuehrlein has a strong interest in medical student and resident education, particularly surrounding addiction psychiatry. He currently serves on the medical school admissions committee, residency recruitment committee and is the VA site representative for medical student education. He serves nationally on the ABPN MOC test writing committee and the education committee for the American Academy of Addiction Psychiatry. In 2017, he was awarded the Irma Bland award for excellence in psychiatry resident education through the APA. In 2018, he was awarded the Clerkship Faculty Teaching Award for Outstanding Medical Student Educator and Role Model. In 2016-2017 he was nominated for and completed the Yale Medical Education Fellowship and in 2018 was selected as an Education Scholar through the Association of Directors of Medical Student Education in Psychiatry.

Dolores Breiner is an Intelligence Research Specialist with the Drug Enforcement Administration. Currently assigned to DEA Headquarters in Arlington, Virginia, she is responsible for following, and reporting on, the domestic heroin threat. Prior to her current assignment, she was an investigative analyst assigned to DEA’s New Jersey Division. Ms. Breiner is an Attorney and holds a law degree from the University of Miami, School of Law. She has used her academic background and work experience to assist the DEA in furthering its mission to remove illicit drugs and violent criminals from our neighborhoods, and fight the diversion of licit drugs.